Journal of Pediatric Endoscopic Surgery (2019) 1:49–52
https://doi.org/10.1007/s42804-019-00008-x
SHORT REVIEW ARTICLE
Paediatric robotic surgery and urology: where are we?
Simon Clarke1
Published online: 3 June 2019
© The Author(s) 2019
Keywords  Robotics · Paediatric surgery · Evidence-based
Introduction
The uptake of robotic surgery by paediatric surgeons has
been slower compared to our adult counterparts (Fig. 1).
3 mm minimally invasive neonatal surgery is challenging
with the current robotic platforms and few neonatal cases
have been reported [1–3]. The improved dexterity and lower
complication rate afforded by robotic assisted surgery is the
gold standard for adult procedures such as prostatectomy [4]
and increasingly colorectal surgery [5]. In paediatrics, recon-
structive procedures that involve prolonged and advanced
suturing skills, such as pyeloplasty and fundoplication, were
expected to be most applicable.
This article aims to provide an overview of the current
updated levels of evidence for some of the main procedures
undertaken by paediatric surgeons and urologists using
robotic technology.
Pyeloplasty
The first robotic pyeloplasty was described in 2006 [6]. A
decade later Cundy et al. [7], demonstrated through a meta-
analysis similar outcome results when comparing robotic to
the open approach though no level 1 evidence data were evi-
dent. The main difference between the two approaches was
operative time and cost, with robotic significantly slower
and more expensive. Other multi-centre studies since then
have shown some reduction in hospital stay [8, 9] but a
multi-centre prospective RCT trial would be needed to accu-
rately compare the laparoscopic and the robotic approach.
* Simon Clarke
simon.clarke@chelwest.nhs.uk
1
Chelsea Children’s Hospital, Chelsea and Westminster
Healthcare NHS Fdn Trust, 369 Fulham Road,
London SW10 9NH, UK
The power of such a study would require a large number of
patients, as outcome differences between both modalities is
likely to be small.
Ureteral re-implantation and ureteroureterostomy have
been shown to be comparable in a few small series [10–14].
Vesico‑ureteric reimplantation (VUR)
Fewer studies exist in this field. Kasturi et al. demonstrated
excellent outcomes for vesico-ureteric reflux using a robotic
assisted approach [15]. Smith et al. compared outcomes of
resolution of VUR with the open approach. They found no
significant differences when using the robot though com-
plications such as bladder and ureteral leak did seem to be
more frequent [16]. The open group demonstrated a higher
rate of post-operative bladder spasm and therefore the over-
all frequency of complications was described as equivocal.
Both reports discuss a shorter length of stay when compared
to the open approach.
Nephrectomy and hemi‑nephrectomy
The adult literature produced a meta-analysis describing
favourable results with robotic nephrectomy compared
to laparoscopic [17]. A lower conversion rate to radi-
cal nephrectomy, renal function using indexed estimated
glomerular filtration rate, a shorter length of hospital stay,
and a shorter warm ischemia time, all were improved with
robotic procedures. In 2015 Till et al., also published a meta-
analysis examining eleven paediatric studies that reported on
the differences between conventional laparoscopy compared
to laparoscopic single site and robotic surgery, in relation to
partial and total nephrectomy [18]. The paediatric data did
not offer any clear advantages over conventional laparoscopy
and the operative time and cost was significantly increased.
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50

Anti‑reflux surgery

Laparoscopic anti-reflux surgery in children has very

favorable outcomes in children when compared to the open
approach [19].
The majority of publications involve the fundoplication.
The demand on the surgeon for this procedure in terms of
suturing is considerably less than that of a reconstructive
urological procedure though awkward angles and hiatal her-
nia reconstruction can be more involved, hence the robotic
approach could offer advantages (Figs. 2, 3). Darzi’s group
in 2015 published a meta-analysis [20] which did not dem-
onstrate any significant differences though a need for dila-
tation following a presumed tight wrap, was more frequent
in the laparoscopic and robotic procedures. There were no
level-1 evidence studies.
A similar group in Leeds also reviewed a prospective
database to examine the learning curve for robot-assisted
fundoplication [21]. Statistically significant transitions
beyond the learning phase were observed at cases 42, 34,
and 37 for docking, console and total operating room times,
respectively. A steep early learning phase for docking time
was overcome after 12 cases.
Fig. 1  View of the console for robotic procedures

There were, however, far few patients in the paediatric data

studies. Cholecystectomy and splenectomy

No published studies to date have demonstrated a significant

benefit to the paediatric patient when comparing robotic with
laparoscopic. Unlike fundoplication, no direct comparisons

Fig. 2  Operation room view and

team setup for robotic proce-
dures

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Paediatric robotic surgery and urology: where are we? 51
Fig. 3  View of the robotic arms during a laparoscopic fundoplication
have been made and recent data so far consist mostly of case
series [15, 22]. The main advantage that these cases seem to
offer is that of useful training experience for robotic skills.
Hepaticoenterostomy
Roux-en-Y hepaticoenterostomy for choledochal cyst exci-
sion involves delicate portal dissection and a sutured anas-
tomosis. Robotics again would seem to offer the paediatric
hepatobilary surgeon significant advantages though to date
there are few case reports [23, 24].
Case reports and small series have been published that
describe a range of other general paediatric surgery proce-
dures such as diaphragmatic hernia repair [2, 25], Heller’s
cardiomyotomy for achalasia [26, 27], duodenojejunostomy
for SMA syndrome [28], duodenal atresia repair [3], and
anorectal pull-through for anorectal malformations [15].
Currently these case studies are mostly demonstrating fea-
sibility rather than equivalence/superior outcomes.
Cost effectiveness of robotic surgery
The cost of a setting up a robotic surgical program is sig-
nificant. Even once established, the ongoing costs can be
prohibitive to many paediatric units. Various publications
examine the different procedures when compared to stand-
ard laparoscopy. A group from Indiana examined open and
robotic pyeloplasty over a 9-year period in 18 American
children’s hospital [29]. They found an increased cost per
case by nearly $4000 for robotic surgery. The length of stay
was shorter, but this still did not offset the significant pro-
cedural cost difference. The increased charges were cited as
mainly operating theatre and anaesthetic charges. As patents
expire and an increasing competitive market grows, outlay
costs will no doubt reduce.
Conclusions
Robotic procedures in paediatric surgery are increasingly
reported. The Patient Health Information System in the US
reports an increase of 19.8% year on year since 2008 [29].
Financial restrictions in many European public health mar-
kets will likely demonstrate a reduced growth when com-
pared to the US. Over the next decade, the introduction of
new, more affordable robotic platforms is likely to alter this.
Open Access  This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat​iveco​
mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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